Annals of Coloproctology

Volume 17(5); October 2001

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Original Articles

Ambulatory Hemorrhoidectomy under Local Anesthesia.: Kim, Jae Han , Kim, Byung Cheol , Jang, Jeong Hwan , Kim, Cheong Yong; J Korean Soc Coloproctol. 2001;17(5):213-219.

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Abstract PDF: PURPOSE
Hemorrhoidectomy can be associated with severe pain in the immediate postoperative period. The aim of this study was to evaluate the advantages and feasibility of hemorrhoidectomy under local anesthesia (pudendal nerve block).
METHODS
From september 1998 to August 2000 we performed 77 hemorrhoidectomy with local anesthesia in our Colorectal unit under the ambulatory surgery regimen. 0.5% lidocaine and 0.25% bupivacaine mixed by 1:1 ratio were used for pudendal nerve block and local anesthesia.
RESULTS
Using pudendal nerve block, ambulatory hemorrhoidectomy with or without band ligation were done in 77 patients. Male to female ratio was 46:31, mean age was 35.2 years. 3 major piles plus 1 minor pile were present in 40 patients (51.9%). We injected mixed lidocaine and bupivacaine solution through external sphincter and puborectalis muscle. All patients were successfully operated without conversion to general anesthesia or even intravenous anesthetic injection. Postoperative pain of them were compared the patients who were operated hemorrhoidectomy under general (spinal or caudal) anesthesia during the same time. The pain were assessed using verbal rating pain scale at 24 hours, 48 hours and 72 hours (1-10, where 1 presented no pain and 10 represented the worst pain imaginable) by phone call examination. Mean pain scores for pudendal anesthesia group at 24, 48, 72 hours were 5.32, 3.07 and 2.21, respectively, compared with other anesthesia group with 6.47, 4.52 and 3.24. These differences were statistically significant (P value<0.05). Post operative pain was successfully controlled with home care and oral medications.
CONCLUSIONS
Under local anesthesia with pudendal nerve block, ambulatory hemorrhoidectomy were able to decrease pain and urinary retension in comparison to spinal or caudal anesthesia group. Ambulatory hemorrhoidectomy is useful, low cost and feasible.

Perineal Rectosigmoidectomy with Levatoroplasty for Rectal Prolapse Early functional outcome.: Yoon, Seo Gue , Lee, Jong Ho , Yoon, Jong Seob , Kim, Kuhn Uk , Kim, Hyun Shig , Lee, Jong Kyun , Kim, Kwang Yun; J Korean Soc Coloproctol. 2001;17(5):220-226.

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Abstract PDF: PURPOSE
This study was designed to analyze the short-term clinical and functional outcomes of perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse.
METHODS
The data were prospectively collected and consisted of the clinical data, the functional status before and after surgery, the operation record, and the postoperative course. The functional status was evaluated by using Wexner's constipation score (0-30), Wexner's incontinence score (0-20), anorectal manometry, and pudendal nerve terminal motor latency. Follow-up was performed at 3-6 months after the operation by using both a standardized questionnaire completed in the outpatient clinic or telephone interview (n=23) and an anorectal physiology test (n=7).
RESULTS
During a one-year period, 23 patients (male=10) underwent perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse. The median duration of the operations was 88 minutes. The median length of postoperative hospital stay was 6 days. There was one urinary tract infection and no mortalities. The constipation score was significantly decreased after the operation (9.8 vs 3.8; P<0.001), and constipation was improved in 90 percent (19/21) of the cases. The incontinence score was significantly decreased after surgery (mean preop.=11.6, postop.=3.7; P<0.001) and incontinence was improved in 17 of 21 patients with impaired continence (81 percent). Anal sphincter function was not improved but rectal reservoir capacity was significantly decreased after surgery (rectal urgent volume (45.7 cc vs 37.1 cc; P=0.045), maximal tolerable volume (120 cc vs 85.7; P=0.011). Most patients (83 percent) felt that the operation had improved their symptoms. The major reasons for dissatisfaction after surgery were frequent defecation, fecal soiling, persistent or aggravated fecal incontinence, and recurrence. One patient had a complete recurrence (4.3 percent), and another patient had a mucosal prolapse which was treated.
CONCLUSIONS
Perineal rectosigmoidectomy with levatoroplasty for complete rectal prolapse is a safe technique with acceptable short-term functional results; however, it is not recommended for rectal prolapse patients with diarrhea-predominant irritable bowel syndrome.

The Ultraslow Wave in Patients with Hemorrhoids and Chronic Anal Fissure.: Kim, Jin Cheon , Kim, Sook Yeong , Kim, Hee Cheol , Yu, Chang Sik , Park, Sang Kyu; J Korean Soc Coloproctol. 2001;17(5):227-231.

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Abstract PDF: PURPOSE
We assessed the nature of the ultraslow wave in patients with hemorrhoids and chronic anal fissure according to clinical findings and manometry in this study.
METHODS
Three hundred and thirty-three patients with hemorrhoids and 88 patients with chronic anal fissure were included. Anorectal manometry was performed according to a modified protocol based on the Coller's study. The ultraslow wave was determined as an undulating wave equal or less than two waves/min.
RESULTS
The ultraslow wave was found in 142 of the 333 patients (42.6%) with hemorrhoids and 44 of the 88 patients (50%) with chronic anal fissure. The pressure variables (maximal resting and squeeze pressure, rectal pressure at the beginning of rectoanal inhibitory reflex, rectal pressure on sense or fullness of balloon) were significantly higher in patients with ultraslow wave than in those without (P<0.001-0.05). The ultraslow wave frequency was inversely proportional to aging and to its amplitude (P=0.006 and <0.001, respectively). Maximal squeeze pressure was closely correlated with maximal resting pressure in a multiple regression analysis (P=0.002). The defecation difficulty and anorectal bleeding were more frequent in patients with ultraslow wave than those without in the hemorrhoids (P=0.008 and 0.021, respectively).
CONCLUSIONS
The ultraslow wave closely correlates with an anorectal pressure and frequently occurs in patients with hemorrhoids and chronic anal fissure. It appears to be associated with the internal anal sphincter as well as with the external anal sphincter and levator ani muscles.

Sigmoid Volvulus: Is Surgical Treatment Mandatory?.: Park, In Ja , Yu, Chang Sik , Cho, Young Kyu , Hong, Hyoun Kee , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2001;17(5):232-238.

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Abstract PDF: PURPOSE
The standard treatment for sigmoid volvulus has been considered as a resection of involved segment after nonoperative decompression. This study was performed to investigate the clinical characteristics and compare the results of managements in patients with sigmoid volvulus.
METHODS
We recruited twelve patients with sigmoid volvulus registered and treated at Asan Medical Center during 1989 and 1999. The medical records were reviewed retrospectively. Telephone inerviews were performed to inquire recent status. We analyzed clinical variables including symptoms on admission, physical findings, findings of radiologic studies, managements and their outcomes. The median age was 64 years (range:45 to 84 years). The median follow-up period was 46 months (range:2 to 94).
RESULTS
Nine patients among twelve were male. Presenting symptoms were abdominal pain (92%), abdominal distension (67%), constipation (50%) and hematochezia. The diagnostic modalities utilized included plain film of the abdomen, CT scan and sigmoidoscopy. Nine cases (75%) were correctly diagnosed prior to operation, of which eight (67%) were diagnosed by plain film. The remaining three cases were by operation. In these cases, preoperative diagnoses were ischemic colitis and obstruction due to colonic malignancy. In seven cases, only nonoperative managements were employed. Nonoperative management included decompression by nasogastric tube or rectal tube insertion and use of bulk forming agents and stool softner afterwards to improve bowel habits. Five patients underwent anterior resection. We couldn't perform surgery in seven cases because of high operative risk due to underlying serious medical conditions such as bronchial asthma, malignancies and refusal by the patients after clinical improvement in 4 and 3cases, respectively. Three of them were died of underlying disease or sepsis. Recurrence occurred in two patients (50%) who underwent nonoperative management only and none in patients who underwent surgical intervention.
CONCLUSIONS
In patients with sigmoid volvulus, elective surgery after appropriate nonoperative management is mandatory to prevent recurrence and fatal outcome, especially in good surgical risk patients. Considerable patients, however, did not undergo surgery due to poor physical status or refusal of surgery.

Effect of Nalbuphin Dosage and Incision Length of Abdominal Wall on Return of Bowel Function after Colectomy.: Kim, Won Il , Park, Won Cheol , Lee, Kyoung Keun , Lee, Jeong Kyun; J Korean Soc Coloproctol. 2001;17(5):239-242.

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Abstract PDF: PURPOSE
Nalbuphin has definitive advantages over the more commonly used narcotic analgesic:a ceiling respiratory depression, little effect on the cardiovascular system and a lower incidence of nausea and vomiting. The use of a small incision results in early return of bowel function and shortening of hospital stay. Narcotic use has been felt to be proportional to the length of the abdominal incision. The aim of this study was to determine whether return of bowel function after colectomy in the postoperative period and incision length were directly proportional to the narcotics.
METHODS
38 patients undergoing colon and rectal resection for benign and malignant colorectal disease between July 2000 and April 2001 participated in this study. Nalbuphin and ketorolac was administered continually by patient controlled analgesia for 48 hours. Additional nalbuphin was used for further pain control. Patients were followed for return of bowel function as measured by first audible bowel sounds, first passage of flatus and first defecation.
RESULTS
There was a significant correlation between the amount of total nalbuphin administered and return of bowel function as measured by bowel sound (r=0.89; P=0.01), time to first passage of flatus (r=0.76; P=0.01), and time to first defecation (r=0.58; P=0.05). Incision length did not show any correlation with either nalbuphin use or return of bowel function.
CONCLUSIONS
There is no apparent benefit for lesser incision length. Return of bowel function is influenced by use of postoperative nalbuphin. So adequate sized abdominal incision is needed and lesser use of narcotics is more beneficial for the return of bowel function.

Surgical Treatment for Diverticular Disease of the Colon.: Chung, He Doo , Park, Kyu Joo , Heo, Seung Chul , Kang, Sung Bum; J Korean Soc Coloproctol. 2001;17(5):243-250.

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Abstract PDF: PURPOSE
To evaluate clinical features of patients who underwent surgical treatment for diverticular disease of the colon.
METHODS
We retrospectively reviewed the hospital records of 27 patients who were surgically treated for diverticular disease of colon at the Seoul National University Hospital from July 1993 to September 1999. We also compared our data with that of previous study of 24 patients surgically treated for the same disease from March 1982 to June 1993.
RESULTS
Although the changes in the distribution of age and sex are not remarkable, increment of total number of left side colonic diverticular disease was noted (from 3 cases among 24 cases in previous study to 11 cases among 27 cases in this study). In contrast to all of right side diverticulitis were classified to stage I or II, half of left side diseases were advanced to stage III or IV by Hinchey's severity classification. Patients with right side diverticular disease were treated with surgical resection of diseased colon with low postoperative morbidity. On the other hand, patients with left side diverticular disease were treated with variety of surgical modalities from drainage alone to staged operation and there were relatively high postoperative complications including 3 cases of reoperation due to peritonitis, and one case of reoperation due to recurred diverticular disease.
CONCLUSIONS
Recent increment in surgical treatment for left side diverticular disease of the colon was noted. Operations for left side colonic diverticular disease, associated with relatively advanced disease stage, exhibited high emergency operation rate and complications.

Expression of p27 Protein in Adenoma and Adenocarcinoma of the Colorectum.: Son, Hyun Jin , Kang, Myoung Jae; J Korean Soc Coloproctol. 2001;17(5):251-258.

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Abstract PDF: PURPOSE
The cyclin-dependent kinase inhibitor p27kip1 protein is a negative regulator of the cell division cycle, and its degradation is required for entry into the S phase. Loss of p27(kip1) protein expression has been reported to be associated with aggressive behavior in a variety of tumors of epithelial and lymphoid origin. The purpose of this study was to determine the expression of p27 protein in adenoma and adenocarcinoma of the colorectum and to assess the prognostic significance.
METHODS
We performed immunohistochemical staining for expression of p27 protein in adenomas (20 cases) and adenocarcinomas (30 cases) of the colorectum. The data (p27 protein labeling index (LI, mean+/-standard deviation)) were analyzed in association with clinicopathologic parameters.
RESULTS
p27 protein LI of normal mucosa (10 cases), adenoma, and adenocarcinoma were 93.3+/-4.5, 65.4+/-17.5, and 28.2+/- 14.5, respectively (p<0.0001). p27 protein LI of well differentiated adenocarcinoma was slightly higher than those of moderately and/or poorly differentiated adenocarcinoma, but did not show any significant difference among these groups (p=0.19). Also p27 protein expression did not show any significant relationship to other prognostic facters such as age, invasion depth, and operative staging.
CONCLUSIONS
The results suggested that reduced expression of p27 protein may play an important role in the malignant transformation process of colorectal cancer.

Expression of Cyclooxygenase-2 in Colorectal Adenocarcinoma.: Kim, Hyung Suk , Heo, Tae Gil , Hong, Seong Woo , Joo, Mee , Jang, Yeo Gu , Kweon, Do Sung , Paik, In Wook , Lee, Hyucksang; J Korean Soc Coloproctol. 2001;17(5):259-266.

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Abstract PDF: PURPOSE
Several studies indicate that nonsteroidal anti-inflammatory drugs including aspirin and sulindac reduce the risk of colon cancer. Futhermore, nonsteroidal anti-inflammatory drugs that inhibit the cyclooxygenase (COX) are shown to inhibit the development colon cancer in animal models of carcinogenesis. COX-1 is constitutively expressed to fulfill its beneficial housekeeping roles. COX-2 is not constitutively expressed by most normal tissues, but it is rapidly induced by certain inflammatory cytokines, tumor promoters, growth factors and oncogenes. The purpose of this study is to evaluate the role of COX-2 in colorectal carcinoma development and the correlation between COX-2 expression and tumor angiogenesis and p53 overexpression.
METHODS
Immunohistochemical analyses using antibodies against COX-2, factor VIII-related antigen, vascular endothelial growth factor (VEGF) and p53 were carried out on archival specimens of 15 colorectal adenoma and 41 adenocarcinoma.
RESULTS
COX-2 expression was increased in 5/15 (33.3%) adenomas and 24/41 (58.5%) adenocarcinomas. COX-2 expression in adenocarcinoma was nearly significantly higher than in adenoma (P=0.050). In adenocarcinoma, COX-2 expression was increased in early cancer (TNM stage) (P=0.028) and well differentiated tumor (P=0.029). COX- 2 expression was not correlated with VEGF expression, microvessel density and p53 overexpression.
CONCLUSIONS
These findings indicate that enhanced expression of COX-2 occurs early during colorectal cancer progression. However, further investigations are needed to evaluate the relationship of COX-2 and tumor angiogenesis using other laboratory methods.

Characteristics of Primary Colorectal Signet Ring Cell Carcinoma.: Kim, In Kyoung , Lee, Ryung Ah , Hwang, Dae Yong , Lee, Seung Sook , Noh, Woo Chul , Bang, Ho Yoon , Choi, Dong Wook , Lee, Jong Inn , Paik, Nam Sun , Moon, Nan Mo; J Korean Soc Coloproctol. 2001;17(5):267-272.

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Abstract PDF: PURPOSE
Primary colorectal signet ring cell carcinoma is a rare disease entity and there is little information compare to ordinary colorectal adenocarcinoma. The aim of this study was to acknowledge the differences of clinicopathological features between colorectal signet ring cell carcinoma and ordinary colorectal adenocarcinoma.
METHODS
The author analyzed clinicopathological aspects of 742 consecutive surgical patients with colorectal carcinoma operated at Korean Cancer Center Hospital between January 1993 and December 1999. 19 patients with primary colorectal signet ring cell carcinoma were identified. Clinicopathological features and survival data were evaluated in comparison with those of the ordinary colorectal adenocarcinoma in a retrospective study matched for age, gender, and stage.
RESULTS
19 (2.6%) cases of primary signet ring cell carcinoma were identified and 26 (3.5%) cases of mucinous adenocarcinoma were identified. Male-to-female ratio of the signet ring cell carcinoma was 1.4:1. Mean age was 44 16 years and median age was 41year (range, 22-73 year). No patient had Stage I disease. The majority of patients had an advanced tumor stage at the time of diagnosis (15.8 percents StageII, 68.4 percents Stage III, and 15.8 percents Stage IV). Median survival time was only 29months (P=0.0084). In a study matched for age, gender, and stage, a lower survival rate was found for patients with signet ring cell carcinoma (P=0.0021). In contrast to ordinary adenocarcinoma, signet ring cell carcinoma was characterized by a significantly higher incidence of locoregional recurrence (50%) and peritoneal tumor spread (30%), but a lower incidence of hematogenous metastases (10%).
CONCLUSIONS
Primary signet ring cell colorectal carcinoma represents a rare and is frequently diagnosed in an advanced tumor stage, thus showing an overall poorer prognosis than ordinary colorectal carcinoma. A high incidence of locoregional recurrence and peritoneal seeding and a low incidence of hematogenous metastasis are characteristics of signet-ring cell carcinoma. This different pattern of tumor biology would be justified to different management of primary colorectal signet ring cell carcinoma.

Case Reports

A Case of Anal Fistula Which Has an External Opening in Thigh.: In, Seung Hyun , Lee, Heung Woo , Nam, Young Soo , Lee, Kwang Soo; J Korean Soc Coloproctol. 2001;17(5):273-276.

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Abstract PDF: Infection of the anal glands is the most common cause of anorectal abscess. Ductal obstruction may result in stasis, infection, and abscess formation. Drainage of the abscess through the perianal skin, whether spontaneous or operative, may lead to a fistula. the fistula in the fascial or fatty planes, especially within the intersphincteric space, located between the internal and the external sphincter extending into the ischiorectal fascia. Fistulas are usually divided into four main anatomic categories as described by Parks and colleagues in 1976.(1,2) The most commonly occurring is the intersphincteric fistula, constituting 70% of all anal fistulas. The infectious process starting from its origin passes directly downward to the anal margin, but there are some variants of these type of fistulas that are less common and more complex to treat. Transsphincteric (25%), suprasphincteric (4%), and extrasphincteric (1%) fistulas constitute the remaining 30% of other anal fistulas those are not intersphincteric. Extrasphincteric fistula is rare and difficult to treat. It begins from the perineal skin penetrating directly downward to the rectal wall above the levator ani. The tract it forms is completely outside the sphincteric apparatus. There are numerous causes to anal fistulas, including trauma, carcinoma, and Crohn's disease. We report a rare case of a 46 year old male patient with anal fistula which has a long abnormal course and an external opening in thigh. The patient suffered from pain on the external opening for 3 years, with dirty discharge.

Natural Killer (NK) Cell Lymphoma of the Cecum with Perforation:A case of report.: Kim, Ik Yong , Ju, Man Ki , Kim, Jong Seok , Jung, Soon Hee , Kim, Dae Sung , Rhoe, Byoung Seon; J Korean Soc Coloproctol. 2001;17(5):277-282.

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Abstract PDF: Natural Killer cell lymphoma pursued a highly aggressive clinical course, with the aggressiveness and poor prognosis in this biologically distinct primary gastrointestinal lymphoma, a more vigorous systemic therapy should be considered in the addition to surgery. We report an unusual case of aggressive primary Natural Killer cell (NK cell) lymphoma of the cecum. A 38-year old man admitted for intractable fever, diarrhea, and hematochezia. The patient diagnosed as primary NK cell cecal lymphoma with perforation after surgical resection. The primary lesion was deep ulceration with perforation and it revealed metastasis to liver. The immunophenotype of the tumor cell were CD56+, CD3+, UCHL-1+, CD45RO+, polyclonal IGH, TCRr, so confirmed NK cell type lymphoma.

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